DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Tailor’s bunion, right foot.
2. Hallux rigidus, right foot.
POSTOPERATIVE DIAGNOSES:
1. Tailor’s bunion, right foot.
2. Hallux rigidus, right foot.
OPERATION PERFORMED: Bunionectomy with an osteotomy with screw fixation, fifth metatarsal, right foot.
SURGEON: John Doe, DPM
ANESTHESIA: MAC with local.
HEMOSTASIS: Pneumatic ankle tourniquet at 200 mmHg, right.
ESTIMATED BLOOD LOSS: Less than 5 mL.
INJECTABLES: Preoperatively, 18 mL of 0.5% Marcaine plain, intraoperatively 3 mL of 1% lidocaine plain, and postoperatively 2 mL of dexamethasone phosphate.
PATHOLOGY: None.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating table in the supine position. A time-out was called to confirm the patient’s name, procedure to be performed, and location. A well-padded tourniquet was then placed about the patient’s right ankle. Following adequate IV sedation, a local anesthetic block was administered to the right foot and a reverse Mayo block in Mayo block fashion using a total of 18 mL of 0.5% Marcaine plain. The right foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was utilized to exsanguinate the right foot, and tourniquet was inflated to 250 mmHg.
Attention was then directed to the dorsal lateral aspect of the fifth metatarsal at the level of the metatarsophalangeal joint where approximately a 3 cm linear longitudinal incision was made lateral to the extensor digitorum longus tendon. The incision was then deepened via sharp and blunt dissection with care taken to identify and retract all vital neurovascular structures. A linear capsular incision was then made using the entire skin incision at the fifth metatarsophalangeal joint to expose the head of the metatarsal. The periosteal and capsular structures were then carefully dissected free of their osseus attachments and reflected medially and laterally exposing the head of the fifth metatarsal. A sagittal saw was then utilized to resect the lateral bony prominence, and the bone was passed from the surgical field.
Attention was then directed to the medial aspect of the fifth metatarsal head where a V-type osteotomy was made using a sagittal saw. The capital fragment was then distracted and shifted medially into a more corrected position and impacted upon the fifth metatarsal shaft. The C-arm was used to determine the correct positioning and the length of the screw that was needed. Using a standard AO technique and manufacturer’s technique for the Osteomed screw, the 18 mm 2.4 Osteomed screw was inserted across to the osteotomy site, and excellent fixation and compression was noted. A sagittal saw was used to resect the remaining lateral bone shelf. The surgical site was then irrigated with copious amounts of normal sterile saline. The capsular and subcutaneous structures were then reapproximated using 3-0 Vicryl in a simple interrupted fashion. The skin was then reapproximated using 5-0 Vicryl in a running subcuticular fashion.
Attention was then directed to the dorsal medial aspect of the right foot where an approximately 6 cm linear longitudinal incision was made at the dorsal medial aspect of the first ray at the level of the first metatarsophalangeal joint medial to the extensor hallucis longus tendon. The incision was then deepened via sharp and blunt dissection with care taken to identify and retract all vital neurovascular structures. All bleeders were cauterized as necessary. A linear longitudinal capsular incision was then made at the first metatarsophalangeal joint to expose the head of the metatarsal and base of the proximal phalanx. Synovial fluid was expressed upon dissection. The periosteal and capsular structures were then carefully dissected free of their osseous attachments. They reflected medially and laterally thus exposing the head of the first metatarsal and base of the proximal phalanx. Upon exposure of the first metatarsophalangeal joint, large multiple osteophytes were noted at the head of the first metatarsal and base of the proximal phalanx with joint destruction, cartilage erosion, reduced articular cartilage of the head of the metatarsal and limited amount of first metatarsophalangeal joint range of motion was noted.
At this time, attention was directed to the first intermetatarsal space using the original skin incision. The area was deepened via blunt dissection to the level of the adductor hallucis tendon. The tendon was identified and transected at its attachment to the lateral base of the proximal phalanx. A rongeur was then utilized to remove all of the osteophytes at the head of the first metatarsal. Utilizing a sagittal saw, a portion of the dorsal aspect of the head of the metatarsal was removed and passed from the surgical field. At this time, an osteotomy was made at the base of the proximal phalanx perpendicular to the long axis of the proximal phalanx. A power bur was used to smooth all rough edges of bone at the head of the first metatarsal. The base of the proximal phalanx was freed from all its soft tissue attachments and passed from the surgical field in total. At this time, the sizers were used to determine their appropriate size for the Vilex hemi-implant, and it was determined that a 15 x 17 implant would be the adequate size. At this time, the K-wire from the kit was inserted at the central aspect of the base of the proximal phalanx and at the appropriate position for the implant. At this time, C-arm was used to determine the correct positioning, and adequate positioning of the K-wire was noted. The 15 x 17 hemi-implant was then inserted and screwed into the proximal phalanx.
At this time, adequate range of motion was noted with a dorsiflexion of the right hallux. The surgical site was then irrigated with copious amounts of normal sterile saline mixed with antibiotic. The capsular structures were then reapproximated using 2-0 Vicryl in a simple interrupted fashion. The skin edges were reapproximated using 5-0 Vicryl in a running subcuticular fashion. Benzoin tincture was then applied to the skin surrounding both incision sites at the first metatarsal and fifth metatarsal. Steri-Strips were then placed across the incision sites. Postoperative injection was then administered at both surgical sites using a total of 2 mL of dexamethasone phosphate. Bacitracin ointment was then applied at the incision sites, and Adaptic was placed at the incision sites. A postoperative compressive dressing was then applied consisting of gauze and Kling. The pneumatic ankle tourniquet was deflated, and hyperemic response was noted to all digits of the right foot. At this time, a fiberglass slipper cast was applied to the right foot with ample Webril padding. The patient was transferred to the recovery room with vital signs stable and neurovascular status intact to the right foot. The patient was given postoperative instructions.
